Your SlideShare is downloading. ×
Dr Steven Pincus, Royal Melbourne Hospital - Redesigning the ED Model of Care
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Dr Steven Pincus, Royal Melbourne Hospital - Redesigning the ED Model of Care

295

Published on

Dr Steven Pincus delivered the presentation at the 2014 Emergency Department Management Conference. …

Dr Steven Pincus delivered the presentation at the 2014 Emergency Department Management Conference.

The 2014 Emergency Department Management Conference explored areas such as how to improve access to care, clinical redesign, NEAT compliance, patient flow, point of care testing, geriatric care, and enhance the performance of Emergency Department.

For more information about the event, please visit: http://bit.ly/edmanagement14

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
295
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
17
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Redesigning the Emergency Department Model of Care Dr S Pincus Deputy Director Emergency Medicine Royal Melbourne Hospital
  • 2. 6th Annual Emergency Department Management Conference July 2014 RMH ED Accredited Trauma Centre Victorian Infectious Diseases Service Tertiary referral centre for Neuroscience, Nephrology, Oncology
  • 3. Where did we start from July 2013 resources 6th Annual Emergency Department Management Conference July 2014 • RMH ED – 21 Staffed General Cubicles (3 step down) – 6 Resuscitation cubicles – 2 Trauma Cubicles – 15 bed SS unit – 6 ambulance transfer cubicles • 3 open from 12:00-20:30 • 3 open from 15:00-23:30
  • 4. Pre Change MOC Dec 2012- May 2013 • 30726 presentations(168 p.d) • 12547 admissions(69 p.d) (41%) • Ambulance 11068 presentations(60 p/d) – 90% off stretcher time 66 minutes(target 40 minutes) – By pass 1.5% • Overall EDLOS<4hrs 50.8% (target 78%) 6th Annual Emergency Department Management Conference July 2014
  • 5. Patient clerked Triage Nurse Patient arrives Fast Track reg nurse Emergency Resus stream 8 resus/ 3 stepdown cons & reg 6 nurses Gold Stream 7 Cubicles/Queue/WR cons, reg & resident 2 cubicle 1 WR nurses Blue stream 13 Cubicles cons & intern 3 nurses Pre-existing MOC Ambulance transfer cubicles 1 nurse 12:00-20:30 1 nurse 15:00-23:30
  • 6. •Patient safety- longer waits are associated with; –Delays to treatment –Increased left before seen –Worse outcomes • Patient satisfaction • National Emergency Access Targets (NEAT) 2011 4hr KPI - Discharged / Admitted / Transferred • 2012 72% • 2013 78% • 2014 84% • Ambulance Off stretcher time • 90% of patients off stretcher @ 40 minutes 6th Annual Emergency Department Management Conference July 2014 Why Change
  • 7. Know your department • You need access to good information • Our EDIS – Symphony Ascribe – Exportable to Excel – Not dependent on others to get information • Direct observation • Ask your staff to identify problems/issues
  • 8. Issues identified- Generic • Registration process was slow & inefficient – Up to 35 minutes to get a UR • 60 AV presentations per day 60 % admitted >95% triaged to staffed cubicle areas • Triage nurses try to do too much & have limited: – Time to assess patients – Rights to order investigations • Waiting time was largely wasted time 6th Annual Emergency Department Management Conference July 2014
  • 9. Arrivals by stream by hour of day Dec 2012-May 2013 6th Annual Emergency Department Management Conference July 2014 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 NumberofArrivals Hour of day Trauma Resus 15% Fast Track 17% Emergency 68%
  • 10. Emergency Stream Q3 EDLOS minutes 142 186 Discharged wait assess 116 157 329 Admitted Wait Assessment Post Assessment 46% patients 69.6% < cat 3 25.5% <4/24 54% patients 49% < cat 3 62%<4/24 68% of patients 6th Annual Emergency Department Management Conference July 2014
  • 11. Trauma/resus stream Q3 EDLOS minutes 36 142 382 Admissions Wait Assessment Post assessment 56 302 Discharges wait assess 15% of patients ~80% admitted 6th Annual Emergency Department Management Conference July 2014
  • 12. Fast track Stream Q3 EDLOS minutes 17% of patients 1-2 patients / hr 94% Discharged 96% Cat 4/5 121 112 226 Admitted Wait Assess Post Assess 6th Annual Emergency Department Management Conference July 2014 104 86 Discharged wait assess
  • 13. 130 168 Discharged Patients wait assess 68.9 % <4/24 Discharged Patients Q3 EDLOS minutes 38% of Discharged patients were triaged to a staffed cubicle •EDLOS triaged to cubicle 5.6hrs •EDLOS triaged to WR 3.1hrs •10% of discharged patients had a bed request—EDLOS Q3 560 miniutes 6th Annual Emergency Department Management Conference July 2014
  • 14. Admitted Patients EDLOS Q3 minutes 98 153340 Admitted Patients wait assess post assess 97 146 425 Admitted to other units 70% admits wait assessment post assessment 17.2 % <4/24 53.17 % <4/24 94% of admitted patients were triaged to a staffed cubicle 99.5 166.5 100 SS of 30% admits wait assessment post assessment 27.91 % <4/24 6th Annual Emergency Department Management Conference July 2014
  • 15. Myth busting - category 4&5 patients are GP patients • 40-45% of patients • 25% of these patients have a bed requested • 30-50% of these patients are referred by a Dr • 5% of Fast track patients have a bed requested 6th Annual Emergency Department Management Conference July 2014
  • 16. Priorities for the ED • Decrease time to registration • Decrease triage time • Decrease AV off stretcher time • Stream patients according to care requirements rather than arrival mode or likely disposition • Staff to meet demand 6th Annual Emergency Department Management Conference July 2014
  • 17. Priorities for the ED • Each stream has a dedicated care team • Front load assessment and immediate care • Decrease transfer time to & increase the use of Short Stay • Decrease time to referral/bed request <2hrs 6th Annual Emergency Department Management Conference July 2014
  • 18. • Inpatient units take too long to review ED referrals/admits • ED performance dependant on availability of results quickly • 5-10% 0f ED admissions could have been direct admits-alternative access? • Post assessment time(bed) Q3 ~6hrs 6th Annual Emergency Department Management Conference July 2014 Issues/Priorities for the hospital
  • 19. What can you change? • Streaming • Staffing – Roles – Ratios • Processes • Do you have a budget? • Do you have a deadline? 6th Annual Emergency Department Management Conference July 2014
  • 20. • Form team • Meet with craft groups to discuss issues and possible responses • Meet with internal and external consumers • Meet with service providers • What are your peer hospitals doing? • What does the literature say? 6th Annual Emergency Department Management Conference July 2014 Redesigning the MOC
  • 21. • Limit initial registration to bare necessities • Walk-ins register before triage • Parallel registration/triage for ambulance arrival • Bed side registration for time critical patients • Non essential registration details collected bedside during down time 6th Annual Emergency Department Management Conference July 2014 Decrease time to registration
  • 22. • What are the immediate care needs? • More succinct assessment – Presenting problem – Vital signs, Pain score, Triage category • Brief triage comments • Risk screening 6th Annual Emergency Department Management Conference July 2014 Decrease triage time
  • 23. • Parallel triage/registration • In cubicle registration • >98% ambulance arrivals were triaged to cubicle • Triage to location appropriate to presenting problem – Appropriate patients triaged to WR 6th Annual Emergency Department Management Conference July 2014 Decrease AV off stretcher time
  • 24. • Up to 40% of discharged patients were triaged to a cubicle • Triage to ―wrong‖ area increases EDLOS – 2.5hrs > for discharge patients in cubicles 6th Annual Emergency Department Management Conference July 2014 Stream to care needs
  • 25. • Move resources to period of peak demand – May be limited by ratios and agreements • Move resources to meet care needs – Senior Nursing/Medical staff reassigned to assessment area- Grunt Up Front – Create registrars roles by exchanging for HMOs 6th Annual Emergency Department Management Conference July 2014 Staffing
  • 26. • All patients triaged to cubicle stream pass through assessment area • Patients leaving the area will have: – An initial care plan including investigations ordered (not necessarily done) – Will have immediate care needs identified/done – Where appropriate have beds booked • May go – To cubicle, WR, Resus – Direct to SS, ward, RAPU, transit lounge 6th Annual Emergency Department Management Conference July 2014 Front loaded assessment
  • 27. New Streams Patient clerked Triage Nurse Patient arrives WR stream 1-6.5 patients per hour Cons, Reg Reg 1230-2200 Cubicle stream 5 assessment cubicles 17 general cubicles 0.5-4.5 patients per hour Assessment RN cubicle nursing unchanged Cons, Reg & Intern Reg 1230-2200 Resus stream 8 resus + 3 stepdowm 1-2 patients per hour staff unchanged 6th Annual Emergency Department Management Conference July 2014 Bed side registration
  • 28. • Early referral and bed request – Don’t wait for results • Reinforce Hospital admissions policy: – Inpatient units have 90 minutes to review referrals – ED senior staff have right to choose admission unit – Interim orders for stable patients 6th Annual Emergency Department Management Conference July 2014 Improved discharge to wards
  • 29. • Multiple events – Craft group specific – Mixed groups • Multiple modalities/media – Muster slides – Intranet – emails • Multiple times • Reinforce post introduction 6th Annual Emergency Department Management Conference July 2014 Educate, Educate, Educate
  • 30. • Commenced mid November 2013 • Comparative data – December 2012 – May 2013 – December 2013 – May 2014 6th Annual Emergency Department Management Conference July 2014 Outcome
  • 31. 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Hour waiting room cubicle resus Predicted Arrivals over 24/24 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Hour Waiting Room Cubicle Assessment Trauma Resus Actual Dec/May Arrival by stream by hour of day
  • 32. 6th Annual Emergency Department Management Conference July 2014 Change in Demographics 0 5000 10000 15000 20000 25000 30000 35000 Numberofpatients Before MOC change After MOC change 5.21% 6.31% -4.19% 12.50% 26.84% 9.94% 18.34% 1.25% -10.00% -5.00% 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% Percentagechange
  • 33. Ambulance performance * Ambulance Victoria Data - Does not include non-emergency ambulances ~3-5 p/day 59 6466 40 0 10 20 30 40 50 60 70 80 90 100 nbr per day* ave off stretcher 90% off stretcher target 90% 6th Annual Emergency Department Management Conference July 2014
  • 34. 6th Annual Emergency Department Management Conference July 2014 ED Length of stay 0 100 200 300 400 500 600 700 Total (minutes) Total admit Ward admt SS admit Discharged Before MOC change After MOC change 50.80% 17.20% 53.17% 68.88% 56.73% 27% 66.97% 72.60% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% Total LOS<4 hrs Ward adm LOS<4 hrs SS adm LOS<4 hrs Discharged LOS<4 hrs Before MOC change After MOC change Time in minutes % LOS<4/24
  • 35. What did we achieve • Decrease time to registration ✔ • Decrease triage time✔ • Decrease AV off stretcher time✔ – 12.5 minutes – 7.1% of patients moved to WR post assessment • Time to be seen-essentially unchanged ✗ • Decrease time to bed request <2hrs ✓ –  Q3 by 15 to138 minutes 6th Annual Emergency Department Management Conference July 2014
  • 36. What did we achieve • Decrease transfer time to and increase the use of Short Stay✔ –  52 minutes EDLOS, 18% in use • Decrease EDLOS for discharged patients✔ –  13 minutes • Decrease post decision time for inpatient admissions✔ –  95 minutes 6th Annual Emergency Department Management Conference July 2014
  • 37. Issues-What is still to do • Communication and transfer of care • Avoiding duplication • Documentation – All data points • Reinforce principles – Reduce pre-decision time – Triage appropriate to immediate needs – Staff team for each stream – Let Senior ED staff decide disposition 6th Annual Emergency Department Management Conference July 2014
  • 38. New Challenges • Increasing demand – 5.3% increase in presentations pre v post – AV emergency presentations now 67 /day – SS increased to 20 beds 900 admissions per month • Improving the new model – Reduce handover – Redefine SS – a destination not a stream • Sustaining improvements achieved 6th Annual Emergency Department Management Conference July 2014

×